What is the cause of and treatment for a 28-year-old female patient's hyperpigmentation on her neck, who has a history of obesity, is taking Byetta (exenatide) for weight management, and experiences intermittent right upper abdominal pain?

From the Guidelines

The patient's skin changes are likely due to acanthosis nigricans, and I recommend a topical retinoid such as tretinoin 0.025% cream applied once daily to the affected areas on her neck, as well as continuing weight management efforts with Victoza (liraglutide) as an alternative to Byetta (exenatide) for weight management, given its discontinuation 1. The patient's history of obesity and insulin resistance suggests that the skin changes are related to metabolic issues, and addressing these underlying issues will provide the most effective long-term improvement. Some key points to consider in the management of this patient's condition include:

• The importance of weight management in improving insulin sensitivity and reducing the appearance of acanthosis nigricans
• The use of topical retinoids, such as tretinoin, to improve the appearance of the darkened skin
• The consideration of alternative weight management medications, such as Victoza (liraglutide), in patients who have experienced discontinuation of their current medication, such as Byetta (exenatide) 1
• The need for further evaluation of the patient's intermittent right upper quadrant abdominal pain to rule out gallbladder disease, which is common in patients with obesity and those experiencing rapid weight loss, and to consider scheduling an abdominal ultrasound to assess for gallstones or other pathology 1. It is also important to note that the patient's weight management efforts should be comprehensive, including lifestyle modifications such as diet and exercise, in addition to medication therapy, as recommended by recent guidelines on obesity management in adults 1.

From the Research

Skin Changes and Acanthosis Nigricans

• The patient's darkening skin changes on her neck are likely related to acanthosis nigricans (AN), a condition characterized by velvety hyperpigmented plaques on intertriginous areas such as the neck, axilla, and groin 2, 3.
• AN is often associated with insulin resistance, obesity, and type 2 diabetes mellitus, which is consistent with the patient's history of obesity and use of Byetta for weight management 2, 4.

Treatment Options for Acanthosis Nigricans

• Treatment of AN primarily focuses on resolution of the underlying disease processes causing the skin lesions, such as weight reduction and addressing insulin resistance 5, 6.
• Topical treatments such as retinoids, vitamin D analogs, and keratolytics may be used to improve the appearance of the skin lesions, but complete cure and disappearance of lesions are difficult to achieve 3, 6.
• Oral medications such as metformin and rosiglitazone may also be used to improve insulin sensitivity and reduce the appearance of AN lesions 6.

Management and Follow-up

• The patient's interest in continuing Byetta (or a similar medication such as Victoza) for weight management is relevant, as weight reduction is a key component of AN management 2, 3.
• Regular follow-up appointments, such as the scheduled 6-month follow-up, are important to monitor the patient's progress and adjust treatment as needed 2, 3.